Senior doctors refused to work evenings and weekends at scandal-hit Kent maternity unit

Junior staff reluctant to raise safety concerns for fear of harassment and intimidation, report finds

Shaun Lintern
Health Correspondent
Thursday 23 January 2020 12:54 GMT
A criminal investigation has been launched into poor care at East Kent University Hospitals Trust
A criminal investigation has been launched into poor care at East Kent University Hospitals Trust (Alamy)

A group of consultants who repeatedly refused to work evenings and weekends were at the centre of a maternity unit culture that put patients at risk, according to warnings by experts which are revealed today.

Despite damning evidence laid out by the Royal College of Obstetricians and Gynaecologists (RCOG) in a report for bosses at East Kent Hospitals University Foundation Trust, in February 2016, the same mistakes were present in the deaths of other babies at the trust in subsequent years.

The RCOG report, uncovered by Derek Richford, grandfather of Harry Richford, a baby who died at the trust, suggests a culture at Margate’s Queen Elizabeth The Queen Mother Hospital in which junior staff were reluctant to raise safety concerns for fear of harassment and intimidation. Poor behaviour by a group of consultants apparently became normalised and tolerated, the report said.

It has also now been confirmed that despite being made aware of the report, the care regulator the Care Quality Commission (CQC) did not see a copy until January last year. The CQC has launched a criminal investigation into poor maternity care at the trust.

An audit by bosses in 2016 found an attendance rate by consultants of just 68 per cent at the Margate unit.

The report said there were three to four consultants who “consistently” failed to attend the wards out of hours, adding: “This unacceptable practice has continued not to be addressed despite repeated incident reporting, with the result that this unit has developed a culture of failing to challenge these poorly performing consultants.”

A majority of staff told the RCOG team they felt there was little point in raising concerns as action would not be taken.

The report said: “The assessors are concerned that staff on both sites are no longer raising concerns about unsafe practices, conduct or performance of colleagues which affects patient safety or care because this has been done in the past without satisfactory resolution and with harassment of staff. Staff reluctance to raise concerns appears to exist across all specialties in the trust.”

One key paragraph in the report predicted failings central to the death of baby Harry Richford almost two years later. It said: “The assessors are concerned that this practice will result in consultants not committed to teaching and supervision to be on-call with a locum middle grade doctor, potentially of unknown competence, which could impact on the safety of care in the maternity unit.”

An inquest into Harry’s death will conclude tomorrow.

The expert review was commissioned by the trust’s then-medical director Paul Stevens in 2015 amid concerns about the maternity unit, following an inspection by the CQC that saw the trust put into special measures.

The team of experts from the RCOG examined documents and dozens of patient cases and interviewed staff.

They were told consultants were often “doing their own thing rather than following guidelines” and that it was left to midwives to report incidents.

Where safety errors were reported, the review said there was “minimal consultant involvement in investigations”, adding: “If poor consultant performance is identified ... this is not reflected in the action plans. There was a lack of performance management of the consultant body.”

The report found there was a poor level of attendance by senior doctors at meetings and some were guilty of what was described as “disrespectful behaviour”.

The RCOG team also found the trust was using out-of-date guidelines for clinical care – with some having expired in 2011.

It was also told these doctors had failed to carry out “daily labour ward rounds, review women, make plans of care and attend when requested out of hours”.

In one case the report said that where concerns were raised about a consultant, the doctor directly confronted staff who had spoken up. The RCOG said: “This behaviour was allowed by the trust without sanctions.”

Among the specific cases examined by the RCOG, it found the trust had refused to accept any responsibility for the death of one baby whose mother was prevented from giving birth in a midwifery-led unit. In another case the parents of a brain-damaged baby were not offered a meeting to discuss the findings of an investigation.

The RCOG also found midwives using a drug called syntocin to speed up labour without it being prescribed by doctors, which the college said was an “unacceptable potentially dangerous practice”.

It also highlighted several instances of poor practice by doctors not being properly investigated or challenged, and no action taken by the trust to prevent the mistakes happening again.

Since the RCOG report the former medical director Paul Stevens has told a coroner that the trust implemented disciplinary action which included a formal warning, and that one consultant had resigned.

A CQC spokesperson said: “CQC was aware of the [RCOG] report. The trust informed us that they had commissioned a review of their maternity services in 2015, and shared information about the actions being taken forward in response to the RCOG’s findings prior to our September 2016 inspection and after that inspection as part of their improvement plan. However, our records do not indicate that we received the full report before January 2019.

“The trust remains subject to close monitoring and further inspections.”

The East Kent trust today acknowledged it had make mistakes in care and apologised to families.

It said: “Following receipt of the RCOG report, the trust audited consultant attendance at the labour ward handovers and ward round meetings for both weekdays and weekends. On the Ashford site, the audit showed 98 per cent physical attendance, in Margate 68 per cent physical attendance.

“The job plans of the Queen Elizabeth The Queen Mother Hospital consultants were revised to bring them in line with the William Harvey Hospital.

“The physical presence of consultants on the labour ward for the labour ward handovers and ward round meetings at QEQM has continued to be routinely monitored and in the last six months has ranged from 97-100 per cent.”

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